Download PDF
Am J Perinatol 2024; 41(09): 1163-1170
DOI: 10.1055/a-1797-7005
Original Article

Outcomes of Nonvigorous Neonates Born through Meconium-Stained Amniotic Fluid after a Practice Change to No Routine Endotracheal Suctioning from a Developing Country

Gunjana Kumar
1   Department of Neonatology, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
,
Srishti Goel
1   Department of Neonatology, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
,
Sushma Nangia
1   Department of Neonatology, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
,
Viraraghavan Vadakkencherry Ramaswamy
2   Department of Neonatology, Ankura Hospital for Women and Children, Hyderabad, Telangana, India
› Author Affiliations Funding None.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Objective The International Liaison Committee on Resuscitation (ILCOR) 2015 gave a weak recommendation based on low certainty of evidence against routine endotracheal (ET) suctioning in non-vigorous (NV) neonates born through meconium-stained amniotic fluid (MSAF) and suggested for immediate resuscitation without direct laryngoscopy. A need for ongoing surveillance post policy change has been stressed upon. This study compared the outcomes of NV MSAF neonates before and after implementation of the ILCOR 2015 recommendation.

Study Design This was a prospective cohort study of term NV MSAF neonates who underwent immediate resuscitation without ET suctioning (no ET group, July 2018 to June 2019, n = 276) compared with historical control who underwent routine ET suction (ET group, July 2015 to June 2016, n = 271).

Results Baseline characteristics revealed statistically significant higher proportion of male gender and small for gestational age neonates in the prospective cohort. There was no significant difference in the incidence of primary outcome of meconium aspiration syndrome (MAS) between the groups (no ET group: 27.2% vs ET group: 25.1%; p = 0.57). NV MSAF neonates with hypoxic ischemic encephalopathy (HIE) was significantly lesser in the prospective cohort (no ET group: 19.2% vs ET group: 27.3%; p = 0.03). Incidence of air leaks and need for any respiratory support significantly increased after policy change. In NV MSAF neonates with MAS, need for mechanical ventilation (MV) (no ET group: 24% vs ET group: 39.7%; p = 0.04) and mortality (no ET group: 18.7% vs ET group: 33.8%; p = 0.04) were significantly lesser.

Conclusion Current study from a developing country indicates that immediate resuscitation and no routine ET suctioning of NV MSAF may not be associated with increased risk of MAS and may be associated with decreased risk of HIE. Increased requirement of any respiratory support and air leak post policy change needs further deliberation. Decreased risk of MV and mortality among those with MAS was observed.

Key Points

  • Not performing ET suction in NV MSAF infants is not associated with increase in the incidence of MAS.

  • Initiating immediate resuscitation without ET suctioning was associated with decreased risk of HIE but increased receipt of any respiratory support and air leak.

  • Large multicentric trial is required to generate robust evidence.

Keywords

meconium aspiration syndrome - nonvigorous neonate - delivery room resuscitation - endotracheal suction - meconium-stained amniotic fluid

Author Contributions

S. N. conceptualized and designed the study, designed data collection instruments, and reviewed and revised the manuscript. G. K. designed data collection instruments and collected data. S. G. designed data collection instruments, coordinated and supervised data collection, conducted statistical analysis, and drafted the initial manuscript. V. V. R. produced the initial draft, provided intellectual inputs, and critically reviewed and revised the manuscript. All authors approved the final version of the manuscript submitted to the journal for peer review and agree to be accountable for all aspects of the work.




Publication History

Received: 29 August 2021

Accepted: 09 March 2022

Accepted Manuscript online:
14 March 2022

Article published online:
07 June 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Hernández C, Little BB, Dax JS, Gilstrap III LC, Rosenfeld CR. Prediction of the severity of meconium aspiration syndrome. Am J Obstet Gynecol 1993; 169 (01) 61-70
    CrossrefPubMedGoogle Scholar
  • 2 Gelfand SL, Fanaroff JM, Walsh MC. Meconium stained fluid: approach to the mother and the baby. Pediatr Clin North Am 2004; 51 (03) 655-667 , ix
    CrossrefPubMedGoogle Scholar
  • 3 Ballard RA, Hansen TN, Corbet A. Respiratory failure in the term infant. In: Taeusch HW, Ballard RA, Gleason CA. eds. Avery's Diseases of the Newborn. 8th ed. Philadelphia, PA: Elsevier Inc; 2005: 705-722
    Google Scholar
  • 4 Raju U, Sondhi V, Patnaik SK. Meconium aspiration syndrome: an insight. Med J Armed Forces India 2010; 66 (02) 152-157
    CrossrefPubMedGoogle Scholar
  • 5 Tolu LB, Birara M, Teshome T, Feyissa GT. Perinatal outcome of meconium stained amniotic fluid among labouring mothers at teaching referral hospital in urban Ethiopia. PLoS One 2020; 15 (11) e0242025
    CrossrefPubMedGoogle Scholar
  • 6 Levin G, Tsur A, Shai D, Cahan T, Shapira M, Meyer R. Prediction of adverse neonatal outcome among newborns born through meconium-stained amniotic fluid. Int J Gynaecol Obstet 2021; 154 (03) 515-520
    CrossrefPubMedGoogle Scholar
  • 7 Rao S, Pavlova Z, Incerpi MH, Ramanathan R. Meconium-stained amniotic fluid and neonatal morbidity in near-term and term deliveries with acute histologic chorioamnionitis and/or funisitis. J Perinatol 2001; 21 (08) 537-540
    CrossrefPubMedGoogle Scholar
  • 8 Lipkin PH, Davidson D, Spivak L, Straube R, Rhines J, Chang CT. Neurodevelopmental and medical outcomes of persistent pulmonary hypertension in term newborns treated with nitric oxide. J Pediatr 2002; 140 (03) 306-310
    CrossrefPubMedGoogle Scholar
  • 9 Shaikh EM, Mehmood S, Shaikh MA. Neonatal outcome in meconium stained amniotic fluid-one year experience. J Pak Med Assoc 2010; 60 (09) 711-714
    PubMedGoogle Scholar
  • 10 Rawat M, Nangia S, Chandrasekharan P, Lakshminrusimha S. Approach to infants born through meconium stained amniotic fluid: evolution based on evidence?. Am J Perinatol 2018; 35 (09) 815-822
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Bhat R, Vidyasagar D. Delivery room management of meconium-stained infant. Clin Perinatol 2012; 39 (04) 817-831
    CrossrefPubMedGoogle Scholar
  • 12 International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 7: Neonatal resuscitation. Resuscitation 2005; 67 (2-3): 293-303
    PubMedGoogle Scholar
  • 13 Cleary GM, Wiswell TE. Meconium-stained amniotic fluid and the meconium aspiration syndrome. An update. Pediatr Clin North Am 1998; 45 (03) 511-529
    CrossrefPubMedGoogle Scholar
  • 14 Foglia EE, Ades A, Napolitano N, Leffelman J, Nadkarni V, Nishisaki A. Factors associated with adverse events during tracheal intubation in the NICU. Neonatology 2015; 108 (01) 23-29
    CrossrefPubMedGoogle Scholar
  • 15 Nangia S, Sunder S, Biswas R, Saili A. Endotracheal suction in term non vigorous meconium stained neonates-A pilot study. Resuscitation 2016; 105: 79-84
    CrossrefPubMedGoogle Scholar
  • 16 Chettri S, Adhisivam B, Bhat BV. Endotracheal suction for nonvigorous neonates born through meconium stained amniotic fluid: a randomized controlled trial. J Pediatr 2015; 166 (05) 1208-1213.e1
    CrossrefPubMedGoogle Scholar
  • 17 Kumar A, Kumar P, Basu S. Endotracheal suctioning for prevention of meconium aspiration syndrome: a randomized controlled trial. Eur J Pediatr 2019; 178 (12) 1825-1832
    CrossrefPubMedGoogle Scholar
  • 18 Perlman JM, Wyllie J, Kattwinkel J. et al; Neonatal Resuscitation Chapter Collaborators. Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (Reprint). Pediatrics 2015; 136 (Suppl. 02) S120-S166
    CrossrefPubMedGoogle Scholar
  • 19 Edwards EM, Lakshminrusimha S, Ehret DEY, Horbar JD. NICU admissions for meconium aspiration syndrome before and after a national resuscitation program suctioning guideline change. Children (Basel) 2019; 6 (05) 68
    PubMedGoogle Scholar
  • 20 Chiruvolu A, Miklis KK, Chen E, Petrey B, Desai S. Delivery room management of meconium-stained newborns and respiratory support. Pediatrics 2018; 142 (06) e20181485
    CrossrefPubMedGoogle Scholar
  • 21 Kalra VK, Lee HC, Sie L, Ratnasiri AW, Underwood MA, Lakshminrusimha S. Change in neonatal resuscitation guidelines and trends in incidence of meconium aspiration syndrome in California. J Perinatol 2020; 40 (01) 46-55
    CrossrefPubMedGoogle Scholar
  • 22 Oommen VI, Ramaswamy VV, Szyld E, Roehr CC. Resuscitation of non-vigorous neonates born through meconium-stained amniotic fluid: post policy change impact analysis. Arch Dis Child Fetal Neonatal Ed 2021; 106 (03) 324-326
    CrossrefPubMedGoogle Scholar
  • 23 Myers P, Gupta AG. Impact of the revised NRP meconium aspiration guidelines on term infant outcomes. Hosp Pediatr 2020; 10 (03) 295-299
    CrossrefPubMedGoogle Scholar
  • 24 Aldhafeeri FM, Aldhafiri FM, Bamehriz M, Al-Wassia H. Have the 2015 Neonatal Resuscitation Program Guidelines changed the management and outcome of infants born through meconium-stained amniotic fluid?. Ann Saudi Med 2019; 39 (02) 87-91
    CrossrefPubMedGoogle Scholar
  • 25 Barrington KJ, Finer N, Pennaforte T, Altit G. Nitric oxide for respiratory failure in infants born at or near term. Cochrane Database Syst Rev 2017; 1 (01) CD000399
    PubMedGoogle Scholar
  • 26 Kim ES, Stolar CJ. ECMO in the newborn. Am J Perinatol 2000; 17 (07) 345-356
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Ferguson L. External validity, generalizability, and knowledge utilization. J Nurs Scholarsh 2004; 36 (01) 16-22
    CrossrefPubMedGoogle Scholar
  • 28 Burchett HED, Kneale D, Blanchard L, Thomas J. When assessing generalisability, focusing on differences in population or setting alone is insufficient. Trials 2020; 21 (01) 286
    CrossrefPubMedGoogle Scholar
  • 29 Kattwinkel J. ed. Textbook of Neonatal Resuscitation. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics and American Heart Association; 2011
    Google Scholar
  • 30 Weiner GM, Zaichkin J. eds. Textbook of Neonatal Resuscitation. 7th Ed. Elk Grove Village, IL: American Academy of Pediatrics and American Heart Association; 2016
    CrossrefGoogle Scholar
  • 31 Ahanya SN, Lakshmanan J, Morgan BL, Ross MG. Meconium passage in utero: mechanisms, consequences, and management. Obstet Gynecol Surv 2005; 60 (01) 45-56 , quiz 73–74
    CrossrefPubMedGoogle Scholar
  • 32 Lee JS, Stark AR. Meconium aspiration. In: Cloherty JP, Eichenwald EC, Stark AR. eds. Manual of Neonatal Care. 6th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2008: 383-387
    Google Scholar
  • 33 Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress. A clinical and electroencephalographic study. Arch Neurol 1976; 33 (10) 696-705
    CrossrefPubMedGoogle Scholar
  • 34 de Boode WP, Singh Y, Molnar Z. et al; European Special Interest Group ‘Neonatologist Performed Echocardiography’ (NPE). Application of Neonatologist Performed Echocardiography in the assessment and management of persistent pulmonary hypertension of the newborn. Pediatr Res 2018; 84 (Suppl. 01) 68-77
    CrossrefPubMedGoogle Scholar
  • 35 Trevisanuto D, Strand ML, Kawakami MD. et al; International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Tracheal suctioning of meconium at birth for non-vigorous infants: a systematic review and meta-analysis. Resuscitation 2020; 149: 117-126
    CrossrefPubMedGoogle Scholar
  • 36 Nangia S, Thukral A, Chawla D. Tracheal suction at birth in non-vigorous neonates born through meconium-stained amniotic fluid. Cochrane Database Syst Rev 2021; 6 (06) CD012671
    PubMedGoogle Scholar
  • 37 Wyckoff MH, Wyllie J, Aziz K. et al; Neonatal Life Support Collaborators. Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156: A156-A187
    CrossrefPubMedGoogle Scholar
  • 38 Viraraghavan VR, Nangia S, Prathik BH, Madarkar BS, Rani D, Saili A. Yield of meconium in non-vigorous neonates undergoing endotracheal suctioning and profile of all neonates born through meconium-stained amniotic fluid: a prospective observational study. Paediatr Int Child Health 2018; 38 (04) 266-270
    CrossrefPubMedGoogle Scholar
  • 39 Pongou R. Why is infant mortality higher in boys than in girls? A new hypothesis based on preconception environment and evidence from a large sample of twins. Demography 2013; 50 (02) 421-444
    CrossrefPubMedGoogle Scholar
  • 40 Mendez-Figueroa H, Truong VT, Pedroza C, Chauhan SP. Morbidity and mortality in small-for-gestational-age infants: a secondary analysis of nine MFMU network studies. Am J Perinatol 2017; 34 (04) 323-332
    PubMedGoogle Scholar
  • 41 Pandita A, Murki S, Oleti TP. et al. Effect of nasal continuous positive airway pressure on infants with meconium aspiration syndrome: a randomized clinical trial. JAMA Pediatr 2018; 172 (02) 161-165
    CrossrefPubMedGoogle Scholar